What Is Medical Necessity?

Medical Necessity across 2 exams

Medical Necessity appears on the following exams. Each defines it in the context candidates are tested on:

CPC

The principle that services, procedures, and supplies must be appropriate and reasonable based on the patient's condition and supported by diagnosis codes. Coders ensure compliance by verifying that documented diagnoses justify the billed procedures.

CBCS (NHA)

The principle that a service or procedure must be reasonable, appropriate, and consistent with accepted standards of care for a patient's diagnosis in order to be covered by a payer. Claims lacking documented medical necessity are commonly denied.